Table 2 The health workforce policy context in Indonesia, Sudan, and Tanzania

Availability

Availability

Availability

The production of qualified health workers has increased significantly in the last 10 years. The number of medical schools went from 40 in 2003 to 72 (of which 43 were private) in 2013; there were 33 736 physicians in 2010 and 81 131 in 2014, an increase of 140% [19]. There are 313 diploma, 275 bachelor, and 9 master nursing programs formally recognized.^b There were 169 697 nurses working in health facilities in 2010 and 295 508 in 2014, an increase of 74%.

Accessibility

The imbalanced distribution and the insufficient quality of the health workforce are major challenges [20] and an obstacle to achieving universal health coverage [21]. Among the 9 550 health centers, 9.8% are without doctors, 23% are without nutritionists, and 61.7% have no health promotion workers [19]. The geographical distribution of nurses and midwives is less uneven than that of doctors, but there are still important variations [19, 22]. The specificities of the numerous islands and of rural areas outside the main island of Java pose additional challenges to health workforce policies [23–25].

Policy and regulation

The current government’s three priorities for HRH are as follows: production, distribution, and improving the quality and performance of health workers by ensuring that education and training institutions meet national standards [4]. In 2014, one third of medical undergraduate programs were not accredited, and the situation was similar in other health professions. A national examination was introduced in 2013 for medical, nursing, and midwifery students as a condition of access to the register; a similar exam is planned for pharmacy and dentistry graduates [23].

The availability of physicians, nurses and midwives is low in spite of the rapid growth of medical schools from 4 in 1990 to 28 in 2006, and to 34 in 2012, producing about 3 000 doctors per year; the number of nursing and midwifery schools rose from 18 in 2006 to 55 in 2013.

Accessibility

There are major variations in the geographical distribution of health workers: 65% of specialist physicians and 58% of technicians are in the capital, where about 20% of the population lives. Emigration of health workers is a major challenge for the country, particularly among physicians. Not only new graduates but also experienced physicians have left the country to work in Saudi Arabia, the USA, and the UK—though numbers registered there have diminished in recent years because of restrictions on hiring health personnel from poor countries—and also Ireland^c [26–28]. The public sector employs 62% of all health workers, the private sector 34%, and the military, university, police, and voluntary sectors 1% each. It is estimated that 90% of health professionals work in both the public and the private sector [26].

Policy and regulation

The Ministry of Higher Education is responsible for pre-service training. The Sudan Medical Council registers doctors, pharmacists, and dentists, and the National Council for Medical and Health Professions regulates the rest of the qualified health workforce. There is a National Human Resources for Health Strategic Plan 2012–2016 which identified the main challenges as “developing capacity for HRH planning and policies, augmenting equitable distribution, improving performance management systems, improving health workforce production, education and training and strengthening HRH functions at decentralized levels” [29, 30]. There has been a HRH Observatory since 2007 (http://www.who.int/workforcealliance/members_partners/member_list/nhrhobs_sudan/en/) and a Council for Coordination, composed of representatives of ministries, training institutions, the medical council, trade unions, aid agencies and the private sector, meets quarterly to discuss HRH issues [27].

The Ministry of Health and Social Welfare (MoHSW) recognized that shortage of personnel and imbalances in the geographical distribution and in the skill mix of health workers are a major impediment to achieving the health MDGs [31, 32]. In March 2013, there were 64 449 health workers of all categories, including 12 074 in the private sector,^d represented 36.4% of the requirement according to MoHSW standards; qualified workers included 1 135 medical doctors, 1 741 assistant medical officers, 5 950 clinical officers, and 14 096 nurses and midwives [33]. The upgrading and expansion of training institutions is ongoing. Schools of nursing doubled enrollment in 2011. For many years, Tanzania has trained assistant medical officers, a cadre between clinical officer and medical doctor; as the degree is not internationally recognized, their retention rate is high [34].

Accessibility

The number of nurses and doctors per capita is low; nationally, it is increasing for both categories, but in 5 out of 25 regions, it was lower in 2015 than in 2014. Between 2010 and 2015, the number of new staff posted in public services was 77% of available positions (new employment permits approved) [35]. Recruitment in public services is made difficult by the competition from the not-for-profit private sector [36] and by emigration [37]. 74% of physicians work in urban areas, where their ratio to population is 17 times higher than in rural areas; 8% of health facilities are not functional because of the absence of personnel [33]. Absenteeism, low productivity [38–40]; difficulty in recruiting and retaining personnel, and management deficiencies [31] are considered as the main HRH problems.

Policy and regulation

To improve performance, the Tanzania National eHealth Strategy 2013 – 2018 ^e proposes to give healthcare workers access to continuous professional development through e-learning and digital resources. Better remuneration of workers in the health sector is needed [39, 41], as are improved management practices and career development opportunities [42].